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ATTESTATION FORM Candidate for the post of :1 Name in full in Block CAPITAL with aliases, If any(Please indicate if you

have added or dropped at Any stage any part of your name or surname). Present address in full (i.e. village, Thana, and District or House No. Land/Street and Road). Home address in full (i.e. village, Thana District or House No. Land/Street and Road), if originally a resident of Pakistan and address In that Dominion and the date of Migration to Indian Union. 4. Particular of places where you have resided for More than one year during the preceding five year. to Residential address in full (i.e village, Thana and District or House Lane Street and No Road.) Surname Name

2.

From

5.

Father's (a) Name in full with aliases, if any, Present postal address (if dead, give last address) Permanent Home address Profession if in service, give designation and official Address (i) Nationality of :Father Mother Husband Wife Place of Birth of :Husband Wife

(a) (b)

6.

(ii)

(a) (b) (c) (d) (a) (b)

7.

(a)

(d) 8. (a)

Exact date of birth as given in the Matriculation Pass Certificate. Present Age Age at Matriculation Mark of Identification

(a) (b) (c) (d)

Place of Birth, district and State in which it (a) Is situated. (b) District and State to which you belong District and State in which properly is held (c)

(a)

Are you a member of a Scheduled Caste or Scheduled Tribes/Backward Class of Haryana Answer Yes or No and if the answer is Yes state The name thereofif Member of Scheduled Caste, state your religion /Caste, if member of Backward Class, state your Caste.

(a)

(b)

(b)

Educational qualification showing places of education with years in school and colleges since 15 th year of age. Name of School/College with full address. Date of Entering Date of leaving Examination passed

If you have, at any time been employed, give details:Designation of post held or description Period the of work. From to

Full address of office, firm or institution

13.

Are you an Ex-ECO, Ex-JCO or Ex-Serviceman or Or likely to be released ? if so, State the rank (i) Officer (ii) Junior Commissioner Officer; and (iii) Other Rank besides indicating the date of entry and release in the army. Have you ever been convicted by Court of any Offence? If the answer is 'Yes' the full Particulars

of the convictions and the sentences, should be given

Name of two responsible persons of your locality or two References to-whom you are known with full address. Are you married ? If so, please state number of living wives you have. (This information is to be given by male persons only)

I Certify that the foregoing information is correct and complete to the best of my knowledge and belief, I am not aware of any circumstances which might impair my fitness for employment under Government.

Signature of the Candidate Date Place

(Certificate to be signed by a Gazetted officer or member of legislature or other authority prescribed by the appointing authority)

Certified that I have known Shri/ Shrimati/ Kumari for the last years months and that to the best of my knowledge and belief the particulars furnished by him/her are correct. daughter of Shri

Place Date ADDRESS in CAPITAL words on which the Candidate desires further intimation

Signature (Designation of Status and Address)

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